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For the First Time, 45 Counties Could Have No Insurer in the Obamacare Marketplaces

Next year, about 35,000 people buying insurance in Affordable Care Act marketplaces in 45 counties could have no carriers to choose from. This would be the first time that has happened since the marketplaces were opened in 2014.

The estimate is based on a New York Times analysis that also found that about 3 million people in 1,388 counties could have just one insurer available to them.

45 counties with no insurer

1,388 counties with one insurer

WASH.

WIS.

MICH.

WYO.

PA.

IOWA

NEB.

NEV.

DEL.

ILL.

UTAH

OHIO

W.VA.

COLO.

VA.

KAN.

MO.

KY.

N.C.

TENN.

OKLA.

ARIZ.

S.C.

GA.

ALA.

MISS.

TEX.

FLA.

ALASKA

WASH.

WIS.

MICH.

WYO.

PA.

IOWA

NEB.

NEV.

DEL.

ILL.

UTAH

OHIO

W.VA.

COLO.

VA.

KAN.

MO.

KY.

N.C.

TENN.

OKLA.

ARIZ.

S.C.

GA.

ALA.

MISS.

TEX.

FLA.

ALASKA

WASH.

OHIO

MO.

WASH.

WIS.

MICH.

WYO.

IOWA

PA.

NEV.

NEB.

DEL.

ILL.

OHIO

UTAH

W.VA.

COLO.

KAN.

VA.

KY.

MO.

N.C.

TENN.

ARIZ.

OKLA.

S.C.

ALA.

GA.

MISS.

TEX.

ALASKA

FLA.

Sources: Kaiser Family Foundation; New York Times compilation of company announcements. | Note: The map does not include plans offered outside the Obamacare marketplaces. Most Americans get coverage through work or the government.

About 45 percent of counties are expected to have one or no insurer in the marketplaces — where about 12 million people buy their own coverage — unless another carrier steps in.

The analysis started with data from the Kaiser Family Foundation showing which companies currently offer plans in each county and combined that with announcements from insurance companies saying which counties they plan to exit or enter next year.

Some insurance companies are still deciding what they will do in 2018, and others may reverse course, so these numbers could go up or down. But they provide an early look at the direction in which the markets are heading.

Most people who buy insurance in the Obamacare marketplaces receive federal subsidies to offset the cost of premiums. In places without any insurers, customers may not have affordable options.

Typically, markets with fewer insurers have also seen larger increases in prices, according to research by the Robert Wood Johnson Foundation and the Urban Institute.

People whose marketplace has only one insurer may also have fewer plans to choose from, according to Cynthia Cox, an executive at the Kaiser Family Foundation.

Many of these places are in rural areas with few customers, who are costly to cover. Urban or more populated areas tend to offer more choices.

In February, Humana became the first major insurer to pull out of the marketplaces entirely, prompting President Trump to again declare that “Obamacare continues to fail.”

Three months after the Humana announcement, Blue Cross Blue Shield announced that it would step in to fill a void in the Knoxville, Tenn., market. Otherwise, 16 counties in the state would have had no insurance options because Humana is currently the only insurer there.

One insurer

Where Humana has pulled out

Nashville

Knoxville

TENN.

Memphis

Nashville

Knoxville

TENN.

Memphis

This week, Anthem, one of the nation’s largest insurers, announced that it would pull out of the Ohio marketplace in 2018, potentially leaving more than 10,000 people with no option in at least 18 counties.

Ohio counties at risk of havingno Obamacare insurer in 2018

Cleveland

Columbus

OHIO

Cincinnati

Anthem, the only carrier in more than 275 counties outside Ohio, has not committed to offering plans in other states.

Counties covered by Anthem in 2017

299 counties covered only by Anthem

610 counties with at least one other insurer

ME.

WIS.

N.H.

NEV.

N.Y.

CONN.

IND.

OHIO

COLO.

MO.

VA.

CALIF.

KY.

GA.

NEV.

OHIO

COLO.

MO.

VA.

KY.

GA.

ME.

N.H.

WIS.

NEV.

N.Y.

CONN.

OHIO

IND.

COLO.

VA.

MO.

KY.

CALIF.

GA.

If Anthem exited the marketplaces nationally, it would leave nearly 300,000 people at risk of having no marketplace insurer in 2018, Ms. Cox said.

How the Landscape Has Changed

Obamacare marketplaces are already thin in many parts of the country. About a third of counties nationwide have only one insurer, according to data released by the Kaiser Family Foundation.

Counties with one or no insurer

2016

2017

2018

2014

2015

16% of counties

6%

7%

33%

45%

2016

2017

2018

2014

2015

PCT. OF COUNTIES: 16

PCT. OF COUNTIES: 6

PCT. OF COUNTIES: 7

PCT. OF COUNTIES: 33

PCT. OF COUNTIES: 45

2016

2014

2015

16% of counties

6%

7%

2017

2018

33%

45%

2016

2014

2015

16% of counties

6%

7%

2017

2018

33%

45%

The number of counties with just one insurer has more than doubled since 2014, while the number with three or more has declined substantially.

Most Americans get health insurance from a job or government program, but about 22 million people buy individual policies under Obamacare. More than half of them use Obamacare marketplaces, where most of them get a federal tax credit to help pay for coverage.

The rest buy directly from an insurer or broker, outside the Obamacare marketplaces. A recent Times analysis showed that many insurers are now choosing to sell exclusively outside the marketplaces, where their customers are not eligible for federal subsidies.

But because customers cannot use subsidies for these plans, many may not be able to afford coverage.

Sources: Data from 2014 to 2017 are from the Kaiser Family Foundation. Data for 2018 are based on company press releases and news reports and may not be comprehensive.